RESE ARCH BRIEF
Mapping pathways to HIV prevention
Developing evidence-based, people-centred strategies for the use of antiretrovirals
S
ome 34 million people worldwide live with HIV, and
the human and economic costs impose a heavy burden,
particularly on the world’s poorest countries. Over 2
million new infections are reported each year, and existing
prevention options such as condoms, counselling, testing and
needle exchange have not fully stemmed the tide. Clinical
trial data show great promise for antiretroviral (ARV) drugbased strategies to fight HIV. However, the science is rapidly
evolving and real-world implementation is complex, shaped
by local political and social circumstances.
Mapping Pathways is the first study of its kind to
synthesise evidence and views about ARV-based prevention
strategies in diverse global contexts, looking at South Africa,
India and the United States. Six partner organisations
collaborated to review the social, economic and clinical
impacts of four strategies: Testing, Linkage to Care Plus
Treatment (TLC+), which provides linkage to care and
the offer of earlier treatment for HIV-positive people;
pre-exposure prophylaxis (PrEP), which provides ARVs to
HIV-negative people to prevent transmission; microbicides,
topical ARV-based applications, also for use by HIV-negative
people to prevent HIV transmission (still in development);
and post-exposure prophylaxis (PEP), which offers ARVs
to people with a recent possible exposure to HIV. Our aim
is to provide a resource for communities and policymakers
that brings together evidence, voices and views about ARVbased prevention strategies in a manner that lays out a future
agenda for policymaking and further research.
Integrating scientific and societal perspectives
We used four complementary methodologies to provide
‘snapshots’ of a rapidly evolving scientific landscape and
its implications in the three countries. A systematic review
of published literature was an essential starting point to
understand the scientific evidence base and highlight
knowledge gaps. We analysed 520 articles, 40 per cent of
these published since 2011, illustrating the dynamic nature
of the field. To further explore the evidence, we sought the
views of a multidisciplinary panel of HIV experts from the
three countries, using an iterative Delphi-based ‘ExpertLens’
approach to stimulate online debate and insights on patientrelated, social, economic and clinical delivery conditions.
Key insights on ARV-based prevention:
• Structural factors such as cost and access are as
important as individual behaviours
•
Policymakers and communities need more
information to develop successful local strategies
• Local context shapes perception: the same scientific
data will be viewed and interpreted differently by
stakeholders in different countries and groups
A ‘grassroots’ survey captured views and experiences
from 1069 community members who were living with
or alongside people with HIV, or helping to deliver HIV
services, in order to understand the practical challenges
of implementing strategies in different contexts. At the
‘grasstops’, we conducted semi-structured interviews with 38
policymakers and public health stakeholders to clarify the
concerns and evidence needs of a group facing new choices as
a result of rapid scientific advances.
All science is local
The evidence snapshots from this project highlight the
importance of local views and the need for a
multidisciplinary approach to understand why different
strategies may or may not be effective in a particular
community. Context is critically important; for example, the
favourability of the four strategies for the grasstops varied
markedly by country (see Fig. 1).
The literature review highlighted the dominant role of
clinical trials in shaping current policy. We found a strong
focus on efficacy – in terms of trial or laboratory results – but
significantly less evidence on real-world effectiveness. Since
behaviour and adherence are central to success, along with
factors such as cost, access, drug resistance, side effects and
health system capabilities, further research is needed into the
conditions that should now shape community-based ‘trials’.
520
38
relevant articles
reviewed
What does the literature say?
Clinical trial results play dominant role
in shaping current policy
Strong focus on efficacy, limited
evidence on effectiveness
Behaviour central to success
Further research needed to clarify
implementation
What do policymakers say?
Developing evidence-based, people-centred
strategies for the use of antiretrovirals as prevention
Mapping Pathways is a community-led initiative to synthesise evidence and
views on the social, economic and clinical impacts of four prevention strategies
based on antiretrovial (ARV) drugs in South Africa, India and the United States.
New approaches to prevention are needed
LITERATURE
I069
2
million
survey responses
from community
representatives
s'
What are the 'grassroot
perspectives?
decisions
More info needed to make
V-based
how/whether to adapt AR
approaches locally
as prevention
General support for ARVs
istance,
Concerns include drug res
ation, cost
adherence, resource alloc
ved education,
trade-offs, need for impro
systems capacity
concerns varied
Weight given to different
by country/context
COMMUNITY
www.randeurope.org/mappingpathways
interviews with
'grasstops' stakeholders
deaths each year
India – most scepticism that efficacy would
Ÿ
translate to effectiveness
South Africa – concerned about resource
Ÿ
allocation, need for trade-offs
U.S. – most optimistic, willing to accept science
Ÿ
at face value
POLICY
2.5
new HIV
million infections
in 2011
34
people living with
million HIV worldwide
‘‘All science is local’’
Report's foreword by Archbishop Desmond Tutu
Key
insights on
ARV-based
prevention:
Limited evidence available for
policymakers to make decisions on ARVbased prevention
Reluctance to make determinations from
one study
Generally positive, but science
interpreted, framed and perceived
differently based on local context:
Structural factors such as cost and
access are as important as individual behaviours
Policymakers and communities need more
information to develop successful local strategies
Local context shapes perception: the same
scientific data are viewed and interpreted differently
by stakeholders in different countries and groups
The science is dynamic and fast-changing. Providing insight from
diverse communities and stakeholders will enrich policies to ensure that
ARVs can reach their prevention potential at local and global levels.
32
multidisciplinary
experts engaged
What do the experts say?
Online discussion forum harnessed
group wisdom to explore faultlin
es in
evidence
Strong agreement science justifie
s more
funding for earlier treatment
Agreement on importance of adh
erence,
biological reliability of ARVs;
disagreement on importance of
potential
risk behaviour increase
Little consensus on essential deliver
y
conditions
EXPERT LENS
www.mappingpathways.blogspot.com
Figure 1. Cross-country comparison of favourable views on the
four ARV-based prevention strategies
Proportion of respondents with favourable views, by country (%)
100
90
India
South Africa
United States
80
70
60
50
An adaptive approach to innovation policy
40
30
20
10
0
Stakeholders in India were most sceptical that efficacy in one
clinical trial would translate to effectiveness on the ground,
noting cultural barriers and complexity around treatment
and testing. In South Africa, stakeholders were primarily
concerned about trade-offs and resource decisions, while in
the U.S. stakeholders interpreted the scientific data most
optimistically.
The ExpertLens exercise highlighted key faultlines in the
evidence base. The experts agreed that the scientific evidence
justified more funding for TLC+ strategies, and also agreed
on the importance of adherence and biological reliability.
They disagreed on the implications of patient risk behaviours
and on which delivery conditions were essential to success.
TLC+
PrEP
Microbicides
PEP
The grassroots survey showed that people need more
information to make appropriate local decisions. The
weight given to different concerns varied by country, but
the issues raised in each included possible effects such as
drug resistance and adherence, resource and cost trade-offs,
education needs and healthcare capabilities.
While grasstops leaders in all three countries were
generally positive about ARV-based strategies, they were
somewhat reluctant to make determinations on the basis
of one clinical trial or study. The same scientific data
were interpreted, framed and perceived very differently.
MAPPING
PATHWAYS
Developing
evidence-based, people-centred
strategies for the use of
antiretrovirals as prevention
Foreword by Archbishop Desmond Tutu
The scientific landscape is dynamic and fast-changing.
Our approach to understanding the evidence base for
future policy development is an inherently adaptive one.
Our findings suggest we can develop much more tightly
integrated understandings of both the scientific data about
efficacy, which tell us whether recent innovations in the use
of ARV drugs work or not, and the ‘social’, multidisciplinary
data about effectiveness. This approach, drawn from
innovation policy thinking, considers the interplay between
‘physical technologies’ such as drug protocols and trials,
‘social arrangements’ such as health clinics and community
education, and ‘organisational frameworks’ such as regulation
and funding. All three need to be complementary for any
scientific innovation to be useful, appropriate and adaptable.
The next step is to work directly with communities
to map locally driven but globally informed pathways to
effective decisions about ARV-based prevention strategies.
Iterative and reflexive knowledge exchange between
communities will be captured so that real-world insights
across diverse contexts can be shared. This will enrich each
individual pathway and facilitate adaptive policy decisions to
unlock the full prevention potential of ARVs. Strategies must
be successful at a local level before they can have a global
impact.
This research brief describes work done for MERCK & Co. and documented in Mapping Pathways: Developing evidence-based, peoplecentred strategies for the use of antiretrovirals as prevention, by Molly Morgan Jones with Jim Pickett, Joanna Chataway, James Swartz, Ohid
Yaqub, Philip Smith, Kartika Palar, Jessica Terlikowski, Daniella Mark, William McColl, Petal Hackett, Catriona Manville and Peter Glick,
RR-326, 2013 (available at http://www.rand.org/pubs/research_reports/RR326). The RAND Corporation is a nonprofit research institution
that helps improve policy- and decisionmaking through research and analysis. RAND Europe’s publications do not necessarily reflect the
opinions of its research clients and sponsors. R® is a registered trademark.
www.randeurope.org
RB-9719-MERCK (2013)
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